From the Guidelines
For a 72-year-old male with hematuria, uncontrolled hypertension, and history of hyperkalemia from Lisinopril while currently on Diltiazem, immediate medical evaluation is essential to address both the hematuria and the hypertension. The patient should seek urgent care for assessment of the hematuria, which could indicate urinary tract infection, kidney stones, or more serious conditions like bladder or kidney cancer given his age. His blood pressure management requires adjustment, as Diltiazem alone is insufficient. A combination therapy approach is recommended, potentially adding a thiazide diuretic like hydrochlorothiazide 12.5-25mg daily, which can effectively lower blood pressure while helping to reduce potassium levels, as suggested by the 2018 guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. Angiotensin receptor blockers (ARBs) like losartan could be considered as they have less risk of hyperkalemia than ACE inhibitors like Lisinopril. Regular monitoring of blood pressure, kidney function, and electrolytes (especially potassium) is crucial. The patient should maintain a low-sodium diet, limit alcohol, engage in appropriate physical activity, and ensure medication adherence. The hematuria requires diagnostic workup including urinalysis, imaging studies, and possibly cystoscopy to determine its cause, as addressing this underlying issue is as important as controlling the hypertension. Given the patient's history of hyperkalemia with Lisinopril, it's crucial to avoid medications that could exacerbate this condition, and the choice of ARBs over ACE inhibitors is supported by their effectiveness in lowering blood pressure with a potentially lower risk of hyperkalemia, as discussed in the treatment of hypertension in patients with coronary artery disease 1. Additionally, the patient's current medication, Diltiazem, a calcium channel blocker, may need to be adjusted or combined with other agents to achieve better blood pressure control, considering the recommendations for managing hypertension in the context of heart failure and coronary artery disease 1. Overall, a comprehensive approach addressing both the hematuria and the hypertension, with careful consideration of the patient's medication history and potential risks, is necessary to improve outcomes.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Hypertensive or anginal patients who are treated with other formulations of diltiazem can safely be switched to DILT-XR [Diltiazem Hydrochloride Extended-Release Capsules, USP (Once-a-day dosage)] at the nearest equivalent total daily dose. Dosages must be adjusted to each patient’s needs, starting with 180 mg or 240 mg once daily. Based on the antihypertensive effect, the dose may be adjusted as needed Individual patients, particularly ≥60 years of age, may respond to a lower dose of 120 mg.
The patient is currently on Diltiazem, but the dosage is not specified. Given the patient's age (72 years) and uncontrolled hypertension, the dosage of Diltiazem may need to be adjusted.
- The recommended starting dose for hypertension is 180 mg or 240 mg once daily, but individual patients, particularly ≥60 years of age, may respond to a lower dose of 120 mg.
- The dose may be adjusted as needed based on the antihypertensive effect.
- Since the patient has a history of hyperkalemia with Lisinopril, alternative antihypertensive agents that do not increase potassium levels should be considered.
- The patient's blood pressure should be closely monitored, and the dosage of Diltiazem or other antihypertensive agents should be adjusted accordingly 2, 2.
From the Research
Recommended Actions for a 72-year-old Male with Hematuria and Uncontrolled Hypertension
The patient's condition requires careful consideration of their medical history, including the use of Diltiazem and the occurrence of hyperkalemia due to Lisinopril. The following actions are recommended:
- Monitor blood pressure regularly, both in the office and at home, to assess the effectiveness of current treatment and identify any potential fluctuations 3.
- Consider lifestyle modifications as the first-line therapy for hypertension, including weight loss, a healthy dietary pattern with low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 3, 4.
- Given the patient's history of hyperkalemia with Lisinopril, an alternative antihypertensive medication may be necessary. A thiazide or thiazide-like diuretic, such as hydrochlorothiazide or chlorthalidone, could be considered as an add-on therapy to the current calcium channel blocker, Diltiazem 3, 5.
- If the patient's blood pressure remains uncontrolled, combining small doses of drugs acting by different mechanisms may be required, as individualizing treatment can improve blood pressure control 6.
- In cases where the combination of a calcium channel blocker (e.g., Diltiazem) and an angiotensin-converting enzyme inhibitor (e.g., Lisinopril) fails to control blood pressure, adding a diuretic may be more effective than adding a beta-blocker 7.
Considerations for Hematuria
It is essential to investigate the cause of hematuria in this patient, as it may be related to their hypertension or other underlying conditions. Further evaluation, including urinalysis, imaging studies, and potentially a renal biopsy, may be necessary to determine the etiology of hematuria and guide appropriate management.
Ongoing Management
Regular follow-up appointments with the patient's healthcare provider are crucial to monitor their blood pressure, adjust their treatment plan as needed, and address any concerns or side effects related to their medications. Additionally, patient education on lifestyle modifications, medication adherence, and the importance of long-term blood pressure control can help improve treatment outcomes 3, 6.